golden gate regional center participant-directed · pdf fileparticipant-directed services ......

EEMMPPLLOOYYEERR EENNRROOLLLLMMEENNTT PPAACCKKEETT IINNFFOORRMMAATTIIOONN AANNDD CCHHEECCKKLLIISSTT

Phone (English) (877)-522-1053 Administrative Fax: (855)-867-1676 Phone (Cantonese) (877)-522-1055 Timesheet Fax: (855)-597-3876 Phone (Spanish) (877)-522-1054 TTY: (800)-360-5899 Email: [email protected] Web: www.publicpartnerships.com

Golden Gate Regional Center Participant-Directed Services Program

Dear Employer and Participant: You have received this letter and the enclosed forms because Public Partnerships, LLC will be serving as your Fiscal Employer Agent in the Golden Gate Regional Center’s Participant-Directed Services Program. The Golden Gate Regional Center (GGRC) provides services and supports for individuals with developmental disabilities and their families. Their program offers a participant-directed approach to home and community based services. This participant-directed option is designed to assist you as the Employer (the vendorized family member) and your participant, in hiring and directing your own supports in your own home. Public Partnerships, LLC (PPL) will serve as your Financial Management Service (FMS) provider by paying your personal workers and assuming responsibility for managing tax filings and payments on your behalf. You will need to complete the enclosed employer enrollment and tax forms and return those indicated in the accompanying checklist to Public Partnerships for processing. On the following pages you will find the Employer Enrollment Packet Checklist and the summary of each form that needs to be completed. GGRC and PPL are committed to providing you as much support as possible; however, we must adhere to federal and state employment tax laws. Therefore, all the employer and worker forms have to be signed and returned to PPL before a worker can begin providing services. We look forward to working with you! Please mail or fax these completed forms back to Public Partnerships ATTN: CA GGRC Public Partnerships -or- Fax to: (855)-867-1676 7776 S Pointe Pkwy W, Suite 150 Phoenix, AZ 85044

mailto:[email protected]

http://www.publicpartnerships.com/



Employer and PPL Responsibilities

Participant-directed services allow you and your participant to use program funds to hire your own workers. The Employer is the employer and Public Partnerships, LLC (PPL) is your Financial Management Service (FMS) provider. Below is a brief summary of what is done by whom: As employer, you will:

• Complete, sign and send Employer paperwork to PPL • Recruit and hire workers; Download Worker Packets from PPL website or contact PPL customer

service at (877)-522-1053 and ask for a packet to be sent to you; and, Provide Worker Packet to potential workers;

• Verify worker qualifications, including the participant-worker relationship; • Choose whether to authorize Criminal background checks on your potential employees • For Respite care, the worker cannot be the participant’s guardian, conservator, parent or step-

parent; • Help select the services the participant will receive; • Orient, train, schedule, and supervise worker; • Schedule worker to provide services for payment only after being authorized by PPL; • Establish performance evaluation criteria for each worker; • Provide a safe workplace free from excess hazards, employment discrimination, and harassment; • Request worker to perform permitted and planned for duties, as determined in the Individual

Participant Plan. The worker should not perform prohibited services such as administering medication, dressing wounds, and tube feeding; unless authorized as a licensed nurse.

• Verify services provided by the worker by reviewing and approving (signing) timesheets, invoices, and documentation of services rendered, and ensuring submission to PPL in a timely manner;

• Ensure that timesheets are submitted within 3 days of the end of the pay period for the worker to be paid on time, and, not later than 30 days past the day service was delivered;

• Monitor your use of authorized services; • Act in accordance with the policies and procedures outlined in your employment agreement; • Notify worker in advance if services are not required or if participant is no longer eligible for

services; • Accept responsibility for payment of services not authorized in approved spending plan; • Ensure that there is no misrepresentation of time, services, individuals, and/or other

information. As the Financial Management Service Provider, PPL will:

• Process timesheets and issue paychecks to workers semi-monthly. • Withhold appropriate state and federal taxes for each worker. • File quarterly and/or annual forms and tax deposits with State and federal agencies (See below

to learn more about what taxes are withheld) • Issue W-2 Statements to each worker in late January. • Answer all questions that you and your workers have. • Help you and your workers with the enrollment process.





Employer Enrollment Packet Checklist

FFOORRMMSS FFOORR TTHHEE EEMMPPLLOOYYEERR TTOO CCOOMMPPLLEETTEE,, SSIIGGNN,, && RREETTUURRNN TTOO PPPPLL RREEQQUUIIRREEDD:: IINNFFOORRMMAATTIIOONN SSHHEEEETTSS OONN EEAACCHH RREEQQUUIIRREEDD FFOORRMM AARREE IINNCCLLUUDDEEDD IINN TTHHIISS PPAACCKKEETT IRS Form SS-4: Application for Employer Identification Number.

IRS Form 2678: Employer Appointment of Agent.

IRS Form 8821: Tax Information Authorization.

CA DE 1HW: Registration Form for Employers of Household Workers. If you have a driver’s license, you must complete that field on the form.

CA DE 48: Power of Attorney Declaration. Informational sheet included in this packet.

Criminal background Check Authorization Form: This form notifies PPL whether or not you require a criminal background check on your potential employees. This form is found in your workers’ packets. You must complete this form for each individual

worker before they can provide services

NNOOTT RREEQQUUIIRREEDD:: PPL Designation of Guardian/ Power of Attorney Form: Declaration of Representative Form. Form

included in this packet.

Separation of Employment Form: To be completed only if a Worker is fired or quits. Form included in this packet.

Please work with your Social Worker or call Public Partnerships to complete these forms

Please call us at (877)-522-1053 if you have any questions. We look forward to working with you!



If you have any questions please call PPL Customer Service at (877)-522-1053

What is it for? This form tells the IRS that you are going to be an Employer and is used to obtain an Employer Identification Number (EIN) from the IRS. This EIN is used to open state employer accounts and assign all tax deposit and filing responsibility to PPL. Why isn’t my address listed on lines 4a and 4b? Lines 4a and 4b ask for the mailing address to be attached to this employer account. Public Partnerships does not intend to burden you with IRS paperwork. By establishing Public Partnerships’ address as the mailing address on your employer account, Public Partnerships ensures that you will not receive IRS paperwork relating to this program at your home. Who are the people listed in the ‘Third Party Designee’ section? Those are PPL staff members who are experienced obtaining EINs on behalf of participant/employers. These three individuals are the only people who can obtain the EIN on your behalf. What lines do I complete? Public Partnerships has completed the SS-4 in a way that notifies the IRS that even though you will be the official employer of your service providers, you will be using Public Partnerships to file and deposit your employer taxes. If you have applied for an EIN in the past please complete line 18.

IRS FORM SS-4: Application for Employer Identification Number


What is it for? This form tells the IRS that you give Public Partnerships permission to complete tax forms for you. By signing this form, you authorize Public Partnerships to withhold taxes from your employees’ paychecks and deposit those taxes with the IRS. With this form, you delegate the employer tax responsibility to Public Partnerships. If I appoint you as my agent with the IRS Form 2678, what will you be able to do? The IRS Form 2678 only allows us to withhold taxes from your employee’s paychecks and deposit those taxes to the IRS. This form is only recognized by the IRS; other tax agencies do not recognize this form. The 2678 does not authorize us to perform any other tax responsibilities. What liability does PPL take on when I sign the 2678? The IRS Form 2678 subjects Public Partnerships to all provisions of law, including penalties that the employer incurs. When you authorize Public Partnerships as your agent with Form 2678, PPL is responsible by law for correctly representing you. Does the IRS Form 2678 authorize you to file my personal income taxes? No. Public Partnerships only deposits withholding taxes for your employees. Public Partnerships cannot handle any of your personal income tax matters.

IRS FORM 2678 Employer Appointment of Agent


What is it for? This form allows Public Partnerships to discuss your employer withholding account with the IRS. It does not allow these representatives to sign any documents. How is this different than the IRS Power of Attorney form? The IRS Power of Attorney Form allows Public Partnership’s CPA Michael McConville to sign employer tax reports. This form allows 3 specific Public Partnerships representatives to talk and write to the IRS about your employer tax account. Will the Fiscal Intermediary to be able to discuss my personal tax account with the IRS? No. Public Partnerships will only be able to discuss the employer tax forms listed in Section 3b. Public Partnerships will never be able to obtain any personal income tax information with this form. I make all decisions about my life. If I sign this, what decisions can PPL make for me? This form only lets the Public Partnerships talk and write to the IRS. Public Partnerships cannot make decisions about your personal life.

IRS FORM 8821 Tax Information Authorization


What is it for? This form will register the Employer with the California Employment Development Department for the purposes of withholding taxes from your workers & your state employment taxes. What liability will I have for state employment taxes? PPL will file and pay all required tax returns on your behalf. At year end, PPL will produce and distribute form W-2 to your workers. What parts of this form do I have to complete? PPL has pre populated all areas of the form that can be completed at this time. All that is required is a dated signature. Will I receive any correspondence from the EDD? Occasionally, a participant will receive a notice, informational pamphlets, or a report from the EDD. If this should occur, you should contact customer service or fax a copy of the correspondence to PPL’s administrative fax line. We will be happy to assist you with any questions or concerns.

California Form DE 1HW California Employment Development Department California Registration Form for Employers of Household Workers


What is it for? This form allows Public Partnerships to represent you before the State of California Employment Development Department (EDD). How is this different than the IRS Power of Attorney form? The IRS Power of Attorney Form allows Public Partnership’s CPA Michael McConville to sign Federal employer tax reports. This form allows Public Partnerships to talk and write to the EDD about your unemployment account. I make all decisions about my life. If I sign this, what decisions can PPL make for me? This form lets Public Partnerships talk, write and file returns to the EDD. It also designates PPL’s mailing address as the primary address for correspondence from EDD. Public Partnerships cannot make decisions about your personal life.

California FORM DE 48 Employment Development Department Power of Attorney Declaration

Designation of Guardianship Power of Attorney Form

Public Partnerships, LLC CA GGRC Program

7776 S Pointe Pkwy W, Suite 150 Phoenix, AZ 85044 Fax: 855-867-1676

If you have a Legal Guardian or Power of Attorney with whom you consent to PPL sharing information with in regard to your service authorization usage, please complete the attached form and included documentation of either the Legal Guardian or Power of Attorney.

Participant Information

Participant ID Number: __________________________________

Date of Birth: / /

First Name __________________________ Last Name ______________________M.I._____

Address _____________________________________________

City______________________________ State:____________ Zip Code:______________________

Legal Guardian


Address _____________________________________________


Power of Attorney


Address _____________________________________________


Participant Signature: Date: ___________________

POA/LG Signature: Date:____________________

*Please fax (855-867-1676) or mail completed and signed forms to: Public Partnerships, LLC

Designation of Guardianship Power of Attorney Form

General definitions of the roles of a Legal Guardian and Power of Attorney can be found below if you are unsure as to whether or not you have appointed someone to this role.

Legal Guardian: An individual who has the legal authority and duty to care for the participant’s person or property, especially because of the participant’s incapacity or disability. An adult of eighteen (18) years or older, who is of sound mind and not acting under duress, fraud, or influence, may nominate a Guardian of his person or property. Upon incapacitation, this nomination shall be binding once approved by the Court. This nomination must be in writing.

Power of Attorney: An instrument granting an individual the authority to act as agent or attorney-in-fact for the Participant. The purpose of this Power of attorney is to give the person the participant designates broad powers to make health care decisions, including power to require, consent to or withdraw any type of personal care or medical treatment for any physical or mental condition and to admit the participant to or discharge the participant from any hospital, home or other institution, but not including psychosurgery, sterilization or involuntary hospitalization or treatment.

Separation of Employment Form

Separation of Employment Form

Public Partnerships, LLC CA GGRC Program

7776 S Pointe Pkwy W, Suite 150 Phoenix, AZ 85044 Fax: 855-867-1676

Purpose: The purpose of this form is to better document terminations and other separation of employment situations. It also facilitates in a more accurate way of processing unemployment claims and allows PPL to have a better understand the details of the working arrangement.

Worker Name: PPL Worker Number:

Participant Name: Participant ID:

Last day worker physically worked:

Reason for separation (circle only one) Quit Fired Laid off

Did you attach a final timesheet for terminated workers? (circle one) Yes No Please send with final timesheet if worker has been terminated. Worker’s forwarding address: (If applicable)

Details of the Events (Please give a brief description of the conversation you had with the worker on the day of the separation)

*Please fax (855-867-1676) or mail completed and signed forms to: Public Partnerships, LLC

Employer Name (print):

Employer signature Date

Participant Information

UCI Number # ____________________ DOB ____/____/_____

Last Name _____________________ First Name ______________________ M.I. _________

Signature of Employer or Participant _____________________________________ Date _________

Authorized Representative

Please circle either YES or NO which indicates your agreement with and acknowledgement of the following:

Golden Gate Regional Center

Authorized Representative Form

1. I understand that I may designate a family member or friend as an Authorized Representative to assist me in my responsibilities to the extent that I prefer. My Authorized Representative may not act as either my employee or my independent contractor. I understand that if I choose an Authorized Representative, I am not giving up any of my decision-making authority. I understand that I may change my mind and revoke my choice of an Authorized Representative at any time by notifying Public Partnerships LLC, my fiscal employer agent.

2. I want to designate an Authorized Representative to assist me in the Golden Gate Regional Center program with PPL I have discussed the specific assistance I would like from my Authorized Representative. I give my permission for members of the PPL team to contact my Authorized Representative listed below: If you wish to appoint and Authorized Representative, please provide the following information: Last Name___________________ First Name ____________________ M.I.________ Phone (___ ) _____________ Email ____________________ Relation to the Employer ____________________ I agree to serve as the Participant’s Authorized Representative: Authorized Representative Signature______________________________ Date ________ Please note: This is an OPTIONAL form. This form is only required if an individual other than the Employer will be assisting with Employer responsibilities

Injured on the job and need to file a claim? Call our TGA Cross insurance broker:

Gracinda Pereira

(781)224-5734 Direct Phone (781)224-9434 Direct Fax

(978)335-0928 Mobile

401 Edgewater Place, Suite 220 Wakefield, MA 01880

1-800-531-5211 Ext. 5734

When calling, please identify your fiscal agent as Public Partnerships LLC (PPL)

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